Prise de décision partagée: défi dans la pratique et la formation professionnelle Pierrette Guimond, inf., PhD. Université of d’Ottawa Centre de décisions de santé d’Ottawa The title of my presentation is: Shared Decision Making: a model for health professionals The model that I am referring to here is The Ottawa Decision Support Framework. Most of you are already familiar with this model as many of my colleagues have already address or will address the various components of the framework in their presentation of the tools and the decision aids developed using the model. And I’m sure that you have read the extensive publications by Dr Annette O’Connor and her team on the Ottawa Model. Therefore, the object of my presentation today is not to review the already familiar elements of the model but to introduce to you a new component to the existing model, the rationale for doing so and the implications for research, education and practice.

Situation actuelle Nouveau paradigme pour la prestation des soins de santé Nouveau paradigme pour la formation des professionnels de la santé

Problématique Perspective des soins de santé Vision globale de l’individu Complexité des problèmes de santé Complexité du processus décisionnel Approche centrée sur le client The reasons why we decided to expand the Ottawa Decision Support Framework originates from two different field of specialisation: 1. Health care 2. Education Lets first look at the health care perspective. The new patient-centred health care paradigm that has been suggested as appropriate for the 21st century and which is increasingly regarded as a proxy for high quality interpersonal care has been a strong influence on the decision support process. For example, in the development of health decision support frameworks that addresses not only the provision of information to the patient but also understand the complexity of the decision making process by taking into consideration the numerous determinants that impact on a difficult health decision. An other example is the increasing attention to patient participation in the decision making process. This increased complexity of the decision support process and the involvement of the patient have affected the role of the health professional. The practitioner no longer acts as the patient’s guardian, articulating and implementing what he thinks is best for him but he is now a counsellor, a guide and an educator in the decision making process. Therefore, health professional communication tasks are no longer only to inform the patient about his/her disease and treatment but also to create an effective relationship by assessing patient’s concerns, showing understanding and providing support. The ability to communicate effectively is now recognised as a core clinical skills that directly impacts health outcomes and decisions. Compétences du professionnel Application d’un processus décisionnel Habileté de communication

Problématique Perspective de formation Nouveau paradigme Modèle behavioriste Nouveau paradigme Processus Résultats From an educational perspective the problem originates from the fact that the behaviourist model has dominated the health professional curricula for many many decades . This pedagogical approach focuses mainly on the result as opposed to the teaching/learning process. The educator’s role is to transmit the knowledge and the student’s role is to receive the information and answer adequately. The educator plan, organise, present the content, direct and evaluate the learning. The learner acquires skills by observation, repetition and trial and error. This approach has been very successful in learning psychomotor skills. However has not proven very efficient in developing communication skills in health practitioners. The new paradigm is based on the interactions and transactions that occurs between students and professors in which both are engaged in the process of learning. The role of the educator encompass an active, involved dialogue with the learner. This highlighted relationship places primary emphasis upon the teacher’s pedagogic skills in engaging the learners in meaningful dialogue by raising questions centred on the exploration of learners background, knowledge, value and experiences. The emphasis in on the communication process used to assist the learner to learn from his experience and in turn develop his communication skills . As you can see there is very strong parallel in the new paradigms form both disciplines. In health care from the perspective of decision making we are now concerned not only with the final decision but with the process used to make the decision using a patient-centred approach as opposed to a practitioner centred approach. This approach also aims at making the patient more responsible for his/her own health care decisions. In Education we are also concerned with the process as oppose to strictly the end result using a student centred approach as oppose to an educator centred approach. This approach compel students to take the leadership and responsibility for their own learning. Even thought these new paradigms have been widely accepted and agreed upon in theory for quite some times, in practice the transition remains very difficult to implement. Sujet responsable Agent responsable Compétences pédagogiques

Efficacité professionnelle Cadre théorique Efficacité professionnelle Argyris et Schön (1982) One reason for this difficulty in transition is that health professionals are not specifically trained to teach but the educators’ role is very much a part of their daily practice. We tend to assume that because they are competent practitioner they are also competent educators. In order to practice their educator’s role, practitioners have to rely on their experience as learner and in turn they usually teach the way they were taught which is for most in a very directive behaviourist approach even if they believe in a patient centred approach. Argyris and Schon have written extensively on the concept of professional effectiveness. They believe that the congruence between your belief and your action in professional practice is an essential element in professional effectiveness. Théorie exprimée Théorie manifestée Congruence

Implications pour l’éducation Les agents de formation devront changer leur philosophie d’enseignement et leurs pratiques pédagogiques pour refléter le nouveau paradigme au lieu de simplement changer les curriculi. Les praticiens en exercice ainsi que les clients devront apprendre à apprendre de leur expérience dans l’application du processus de soutien à la décision.

Implications pour la pratique Introduire des outils pour assister les professionnels en exercice à apprendre de leur expérience d’application du processus de soutien à la décision. Améliorer l’efficacité des praticiens en réduisant l’écart entre l’attitude exprimée et l’attitude manifestée.

Implication pour la recherche Intensifier les recherches sur le processus manifesté par les praticiens dans un contexte de prise de décision partagée. Evaluer l’efficacité d’un modèle d’apprentissage expérientiel lors de la formation pratique des professionnels à l’application du processus de soutien décisionnel.

Solutions possible Développer chez les professionnels de la santé des habiletés pour apprendre de leur expérience en les encourageant à identifier les éléments clés du processus de soutien à la décision et à appliquer ces principes à des situations futures. Even if the reflective process is a core element in developing professional effectiveness in the decision support process it does not in itself necessarily lead to learning from the experience. Some practitioner may apply the decision making process over an over again, reflect on the experience and essentially repeat the same approach never learning from their experience. In order to ensure that learning occurs from experience it is essential to use a teaching / learning framework. Therefore we choose an experiential teaching/learning framework. Again we have to be careful with this concept of experiential learning as it has been define or view by many authors in professional education as clinical experience. The fact that student are living an experience in a real practice environment does not necessary means that they are using an experiential teaching/learning framework. The same confusion is often seen with some teaching/learning strategies such as role playing or problem based approach to learning.

Éléments de discussion Développer une prise de conscience chez les professionnels de la santé de leur processus de soutien à la décision en les encourageant à réfléchir sur leur pratique. From those result and numerous other research in various disciplines it seems that we have enough evidence to say that it will take more that good intention from the part of the practitioner to make a complete the transition to a patient-centred decision support process. It is in light of those research evidence and our personal experiences with the application of the decision support process that we decided to expand the Ottawa decision Support Framework. Our objectives are directed both at the practitioner and at the patient. We will first look at the model expansion from the practitioners’ perspective because we believe that the change in culture has to start with the practitioner which in turn will be able to assist the patient in the process of transfering learning to future decision making. Our first objective is: 1. To develop the practitioners’ awareness of his/her current application of the decision support framework in guiding a patient in the decision making process by encouraging them to reflect on their practice. From a theoretical point of view we know that we cannot just give the practitioners a quick overview of the framework and expect them to fully understand it and master it’s application in one consultation with a patient. We also know that in term of resources, time and money we cannot expect to launch a large comprehensive training program for exiting practitioners. However, we feel that by giving the practitioners the tools to learn from his or her own practice in applying the Ottawa decision support framework they can in turn learn from their experience and improve their effectiveness in the decision support process. The first step in doing so is to encourage them to reflect on their practice.